BACKGROUND AND PURPOSE:

• Active management of third stage
  • Prophylactic uterotonic | Early umbilical cord clamping | Controlled cord traction
• Uterotonic choice varies
• Salati et al (Cochrane Reviews, 2019) sought to determine the effectiveness of oxytocin to prevent PPH and other morbidities

METHODS:

• Systematic review
  • Searched: Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved studies
• Inclusion criteria
  • Randomized, quasi-, or cluster-randomized trials that included women undergoing vaginal delivery who received prophylactic oxytocin during the third stage of labor
• Primary outcome
  • Blood loss ≥500 mL after delivery
  • Need for additional uterotonics
  • Maternal all-cause mortality
• Data analysis
  • Two authors independently determined trials for inclusion, compiled data, and assessed trial quality
  • The quality of evidence was assessed using the GRADE criteria

RESULTS:

• 23 trials | 10,018 women
  • Quality of evidence ranged from very low to moderate

Prophylactic oxytocin versus no uterotonics or placebo (9 trials)

• Compared to placebo or no uterotonic, prophylactic oxytocin may reduce risk of
  • Blood loss ≥500 mL after delivery: Risk ratio (RR) 0.51 (95% CI, 0.37 to 0.72; low-quality evidence)
  • Blood loss ≥1000 mL after delivery: RR 0.59 (95% CI, 0.42 to 0.83; low-quality evidence)
  • Need for additional uterotonics: RR 0.54 (95% CI, 0.36 to 0.80; moderate-quality evidence)
• No significant difference in transfusion risk
  • RR 0.88 (95% CI 0.44 to 1.78; low-quality evidence)

Prophylactic oxytocin versus ergot alkaloids (15 trials)

• Compared to ergot alkaloids, it is uncertain whether oxytocin reduces the likelihood of
  • Blood loss ≥500 mL: RR 0.84 (95% CI, 0.56 to 1.25; very low-quality evidence)
  • Blood loss ≥1000 mL: RR 1.13 (95% CI, 0.63 to 2.01; very low-quality evidence)
  • Need for additional uterotonics: RR 0.89 (95% CI, 0.43 to 1.81; very low-quality evidence)
  • Need for blood transfusion: RR 1.37, 95% CI 0.34 to 5.51; very low-quality evidence)
• Oxytocin probably increases the risk of a prolonged third stage >30 minutes
  • RR 4.69 (95% CI, 1.63 to 13.45; moderate-quality evidence)
• Oxytocin is probably associated with a lower risk of vomiting
  • RR 0.09, 95% CI, 0.05 to 0.14; moderate-quality evidence)
• Oxytocin’s impact on headaches is uncertain
  • RR 0.19 (95% CI, 0.03 to 1.02; very low-quality evidence)

Prophylactic oxytocin/ ergometrine versus ergot alkaloids (4 trials)

• Compared to ergot alkaloids, oxytocin-ergometrine may slightly reduce the risk of blood loss ≥500 mL after delivery
  • RR 0.44 (95% CI, 0.20 to 0.94; low-quality evidence)

• Note: No subgroup differences were observed between active or expectant management, or different routes or doses of oxytocin for any comparisons

CONCLUSION:

• Based on the above results, the authors conclude

Oxytocin may reduce blood loss and the need for additional uterotonics when given prophylactically in the third stage of labour, and therefore could be considered as a component of active management of the third stage of labour

• Oxytocin may have less side effects than ergot alkaloids but possibly associated with an increased risk of third stage >30 minutes
• Well-designed RCTs will be required to compare ergot alkaloids and oxytocin

Learn More – Primary Sources:

Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage

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